Parkinson’s Disease

PARKINSON’S DISEASE Sintomatologia 1817 Il Morbo di Parkinson è una malattia neurodegenerativa cronica caratterizzata dalla degenerazione e quindi dalla conseguente riduzione del numero di neuroni dopaminergici nigrostriatali Sintomatologia Quattro Sintomi principali: tremore a riposo, rigidità, bradicinesia, alterazione della postura e della deambulazione Sintomi secondari: sintomi cognitivi (demenza), sintomi affettivi (depressione) Although treatment is available to achieve symptomatic improvement, its management is both a challenge and an art. Care of patients with advanced disease need clinical experience, patient cooperation and utilization of all available treatment options.

Sintomi primari 27/03/2017

Sintomi secondari 27/03/2017

PARKINSON’S DISEASE Malattia molto rara in individui < 40 anni uomini > donne Malattia neurodegenerativa cronica molto diffusa (The most common neurodegenerative movement disorder) Sintomi e aspetti neuropatologici ben caratterizzati Non ancora del tutto chiariti i meccanismi patogenetici

DOPAMINA: precursore di noradrenalina e adrenalina DOPAMINA: precursore di noradrenalina e adrenalina. Importante per modulazione attività psichica e motoria, ma anche per tono dell’umore, secrezione alcuni ormoni ipofisari, alcune componenti dei processi cognitivi.

…. a predominantly sporadic disease, the likely cause of PD is currently considered to involve a combination of genetically determined vulnerability and exposure to toxins in the environment…. Emma Lane & Stephen Dunnett, 2008

Eziopatogenesi Degenerazione progressiva e selettiva dei neuroni dopaminergici nigrostriatali D2 D1

STAGES OF PARKINSON'S DISEASE DOPAMINE (% control) 100 80 ADAPTIVE 60 CAPACITY 40 COMPENSATION -no symptoms 20 MILD SYMPTOMS DECOMPENSATION MARKED SYMPTOMS

While most clinical and pathological attention in PD has focused on the dopamine system, it is important to appreciate that cell loss and Lewy body pathology can also be seen in multiple other sites, including cholinergic, norepinephrine, and serotonin neurons in selected regions of the cerebral cortex, olfactory system, basal forebrain, brain stem, spinal cord, and peripheral autonomic nervous system

Neuropathology of Parkinson’s Disease Possibili fattori causali: Genetici stress ossidativo (alterazione funzionalità mitocondri) sistema ubiquitina-proteasoma Ambientali Degenerazione progressiva e selettiva dei neuroni dopaminergici nigrostriatali

PARKINSON’S DISEASE Genetic Factors PD may be multifactorial in etiology with genetic contributions Familial cases are relatively rare (~10%) The younger the age of symptom onset, the more likely genetic factors play a key role At least ten single gene mutations identified

Protein aggregation – Ubiquitin/proteasome system PD è caratterizzato dalla presenza di proteine neuronali che tendono ad assumere una conformazione anomala (PARK1=alpha-synuclein) e polimerizzare formando aggregati intracellulari che portano ad alterazioni dell’attività neuronale e morte neuronale. Le proteine con conformazione anomala sono normalmente degradate tramite il sistema dell’ubiquitina/proteasoma con un meccanismo ATP-dipendente. Disfunzione di questo sistema conduce all’accumulo di proteine danneggiate/tossiche che portano a danno neuronale fino a degenerazione/morte del neurone.

PARK1 = a-Synuclein a-synuclein (PARK 1) is a 140-amino acid presynaptic protein involved in synaptic vesicle recycling, storage and release of neurotransmitters; it is associated with vesicular and membranous structures Three mutations in a-synuclein gene (A53T, A30P, E46K) are associated with early onset PD a-Synuclein has an increased propensity to aggregate due to its hydrophobic domain. The presence of fibrillar a-synuclein as a major structural component of Lewy Bodies in PD suggests a role of aggregated a-synuclein in disease pathogenesis A pathological modification involving phosphorylation of Ser129 in a-synuclein promotes aggregation, and that Ser129 phosphorylated a-synuclein is a major component of LB Mechanisms by which abnormal processing and accumulation of a-synuclein disrupt basic cellular functions leading to dopaminergic neurodegeneration are intensely studied. One of the earliest defects following a-synuclein accumulation in vivo is blockade of endoplasmic reticulum to golgi vesicular trafficking causing ER stress Transgenic mice expressing human A53T a-synuclein develop mitochondrial pathology providing a crucial role of a-synuclein in modulating mitochondrial function in neurodegeneration. This may be due to the fact that a-synuclein is a modulator of oxidative damage, since mice lacking a-synuclein are resistant to mitochondrial toxins a-synuclein has also been shown to activate stress-signaling protein kinases, impair microtubule-dependent trafficking, reduce intercellular communications at gap junctions to promote toxicity. These pathophysiological aspects are detrimental to normal functioning of dopaminergic neurons and provide implications for disease pathogenesis in a-synuclein-induced PD.

Park2= PARKIN gene = E3 ubiquitin ligases Catalyzes the addition of ubiquitin chains to target misfolded proteins before their degradation by the proteasome. Loss of its E3 ubiquitin ligase activity due to mutations lead to early-onset PD. Patients suffer from motor symptoms similar to idiopathic PD including rigidity, resting tremor, and bradykinesia. Patients respond to L-DOPA therapy; however, they develop L-DOPA-induced dyskinesias sooner than patients with idiopathic PD. Pathologically, patients also have a degeneration of nigrostriatal DA neurons but most do not develop Lewy bodies. Parkin functions as a multipurpose neuroprotective protein in a variety of toxic insults crucial for dopamine neuron survival Recent studies suggest that parkin mediates neuroprotection through activation of IkappaB kinase/nuclear factor-kappaB signaling, whereas parkin mutants failed to stimulate this pathway. Parkin knockout mice show a reduction in weight gain, reduced mitochondrial respiration, reduced antioxidant capacity, and increased oxidative damage in the brain.

Oxidative Stress and mitochondrial dysfunction Alcuni dei geni coinvolti nelle forme di Parkinson familiare hanno ruoli intracellulari associati alla funzione mitocondriale e/o neuroprotezione da stress ossidativo (DJ-1; PINK1; LRRK2; PARKIN) Gli inibitori del complesso mitocondriale 1 (MPTP, rotenone) sono in grado di provocare Parkinsonismo con una selettiva neurodegenerazione dei neuroni dopaminergici nigrostriatali sia in vitro sia in modelli animali (roditori e scimmie). L’inibizione del complesso mitocondriale 1 ha due conseguenze principali: deplezione del contenuto di ATP del neurone (e quindi riduzione di tutti i processi cellulari ATP dipendenti) e produzione di radicali liberi che causano stress ossidativo. Numerose evidenze indicano la presenza di stress ossidativo in cervelli di pazienti con PD (analisi post-mortem).

PARK7 = DJ-1 Mutations in the DJ-1 locus are associated with rare forms of early-onset parkinsonism. Many lines of evidence suggest that DJ-1 functions as an antioxidant protein. DJ-1 may function as a scavenger of reactive oxygen species (ROS). Overexpression of wild-type DJ-1 both in cell culture and to dopaminergic neurons in vivo protects against wide variety of toxic injury due to oxidative stress.

PARK6 = PINK1 Mutations in the PINK1 cause early-onset familial PD. PINK1 contains an N-terminal mitochondrial targeting sequences and a highly conserved protein kinase domain similar to ser/thr kinases. Very little is known about the precise function of PINK1 although its mitochondrial localization, presence of kinase domain with identification of majority of mutations in the kinase domain suggest a role in mitochondrial dysfunction, protein stability and kinase pathways in pathogenesis of PD. Only few putative substrates to the kinase have been identified till date In vivo PINK1 disease-causing mutations leads to dopaminergic degeneration as a consequence of mitochondrial dysfunction. Interestingly, this degenerative phenotype was rescued by overexpression of the ubiquitin E3 ligase parkin, implicating the importance of both parkin and PINK1 in regulating mitochondrial physiology and survival. PINK1 mutations lead to increased lipid peroxidation and defects in mitochondrial complex I activity.

PARK8=leucine-rich repeat kinase 2 (LRRK2) Mutations in LRRK2 cause early PD. LRRK2 gene encodes for a 280kDa protein that includes a Ras-like GTPase domain, a protein kinase domain of the MAPKKK family. Point mutations have been found in almost all of the identified domains. Mutations are associated with increased kinase activity of LRRK2. The precise physiological role of this protein is unknown but presence of multiple functional domains suggesting involvement in wide variety of functions. LRRK2 and it seems to be predominantly cytoplasmic especially in the golgi apparatus, synaptic vesicles, plasma membrane, lysosomes and associates with the outer mitochondrial membrane. LRRK2 modulates synaptic vesicle recycling, neurite outgrowth and functions inherent to golgi, lysosomes and mitochondria, dysfunctions of which may compromise dopamine neuron survival.

Models based on the genetic deficits associated with a small percentage of sufferers demonstrate the pathological accumulation of α-synuclein characteristic of the disease but have few motor deficits and little neurodegeneration.

PARKINSON’S DISEASE Possibili fattori ambientali Vita rurale / lavoro nell’agricoltura Fumo di sigaretta MPTP (mitochondrial complex I inhibitor) Pesticidi/erbicidi (rotenone, paraquat) Metalli pesanti (ferro, manganese)

Rotenone Rotenone è un pesticida di uso comune ampiamente utilizzato anche per giardinaggio. It is a high-affinity and specific inhibitor of mitochondrial complex I Chronic systemic low-dose rotenone exposure induces features of PD in rats, including selective nigrostriatal dopaminergic degeneration and formation of ubiquitin- and -synuclein-positive inclusions Marked microglial activation with minimal astrocytosis is another pathological feature; progressive oxidative damage and caspase-dependent cell death are also observed Rotenone model links mitochondrial dysfunction/oxidative stress/ proteolytic stress & pesticide exposure to the mechanism of sporadic PD

PARKINSON’S DISEASE 1-Methyl-4-Phenyl-1,2,3,6-Tetrahydropyridine (MPTP) Synthetic street drug ad azione neurotossica individuata per la prima volta nel 1983 Selettiva degenerazione delle cellule dopaminergiche della sostanza nera in uomini, scimmie e roditori producendo i classici sintomi della malattia di Parkinson. Attraversa BBB, entra negli astrociti dove MPTP viene convertito in MPP+ dalle MAO-B; MPP+ entra nei neuroni dopaminergici attraverso il sistema di ricaptazione della dopamina; porta a deplezione dei livelli intracellulari di ATP bloccando la “respirazione mitocondriale”, in particolare il mitochondrial Complex I. MPP+ ha una struttura chimica simile all’erbicida paraquat e altri derivati isochinolinici ampiamente distribuiti nell’ambiente. Utile per la produzione di modelli animali dove studiare la disfunzione dopaminergica

PARKINSON’S DISEASE Fumo di sigaretta Oltre all’età, il fumo di sigaretta rappresenta il più consistente studio epidemiologico effettuato sul Parkinson con una associazione inversa tra fumo ed insorgenza della malattia. Diminuzione del 50% del rischio di insorgenza di PD tra I fumatori. Nicotina protegge il sistema mitocondriale da alcuni tipi di danni (esperimenti in modelli animali). Nicotina riduce l’attività delle MAO-B.

STAGES OF PARKINSON'S DISEASE Current drugs for Parkinson’s Disease DOPAMINE (% control) STAGES OF PARKINSON'S DISEASE 100 80 ADAPTIVE 60 CAPACITY 40 COMPENSATION -no symptoms 20 MILD SYMPTOMS DECOMPENSATION MARKED SYMPTOMS

Current drugs for Parkinson’s Disease

+ Therapy of PD: limitations of levodopa Does not prevent the continuous degeneration of nerve cells in the subtantia nigra, the treatment being therefore symptomatic. Efficacy tends to decrease as the disease progresses. Chronic treatment associated with adverse events (motor fluctuations and dyskinesias). Most dyskinesias occur in association with peak plasma L-dopa concentration and maximal clinical response (peak-dose dyskinesia). Motor complications are most prominent in younger patients and in those who take high dose of levodopa. In the extreme, patients can cycle between ‘‘on’’ periods complicated by severe dyskinesia and ‘‘off’’ periods when they are severely Parkinsonian. Levodopa does not however prevent the continuing degeneration of nerve cells in the substantia nigra, the treatment being therefore symptomatic. Koller, WC and Minagan, A. Treatment strategies for the management of Parkinson’s disease. In: Parkinson’s disease management guide, Medical economics Company Inc. at Montvale NJ, pp. 101-1332001. +

GENERAL TREATMENT STRATEGIES FOR MOTOR COMPLICATIONS (Dyskinesias) Individualize treatment Adjust medication combination Substitute controlled-release with regular levodopa Dose levodopa regularly Smaller doses of levodopa; increase frequency

SPECIFIC TREATMENT STRATEGIES FOR MOTOR COMPLICATIONS (Dyskinesias) Add Dopamine agonist Add COMT inhibitor (tolcapone) or a MAO-B inhibitor (Rasagiline) Amantadine

Principali farmaci attivi sui recettori Dopamina I principali farmaci presenti in commercio sono: Pergolide mesilato(Nopar®), derivato semisintetico che agisce su D1 e D2 utilizzato in ogni fase della malattia, ben assorbito per via orale, il cui dosaggio medio giornaliero è di 2-3 mg. Bromocriptina (Parlodel®) utile in tutti gli stadi della malattia e per tutti i principali sintomi, solo o associato con la levodopa. Lisuride (Dopergin®), utile negli stadi di maggiore gravità ma con frequenti effetti collaterali psicotici (allucinazioni visive) dosaggio dipendenti, somministrato per via orale e parenterale. Ropinirolo (Requip®) e Pramipexolo (mirapexin®) recenti farmaci di sintesi con struttura dopamino- simile, sono ben tollerati, hanno buona efficacia, minori effetti collaterali.

Inibitori enzimatici Un altro approccio alla malattia è quello di ripristinare la quota di dopamina che non viene prodotta andando a sfruttare il meccanismo dell’inibizione enzimatica di MAO e COMT responsabili della catabolizzazione della dopamina. Si distinguono in inibitori delle MAO-B (selegilina) e delle COMT (tolcapone, entacapone).

Unified Parkinson’s Disease Rating Scale (UPDRS)

Cell-based therapies that involve transplantation into the striatum of fetal dopaminergic cells have attracted considerable interest as possible treatments for Parkinson’s disease (PD). Implanted fetal dopaminergic cells can survive, reinnervate the striatum, and improve motor function in rodent and primate models of PD Long-term follow-up studies suggest that individual transplantation patients have done very well and in some instances can even be maintained with minimal or even no levodopa. However, all double-blind, sham-controlled, studies have failed to meet their primary endpoints, and transplantation of fetal dopamine cells is associated with a potentially disabling form of dyskinesia that persists even after withdrawal of levodopa.

50% of transplantation patients develop a novel and previously unreported form of involuntary movement referred to as “off-medication dyskinesia” : Graft-related dyskinesias have been described L-DOPA induced dyskinesias because they can persist for prolonged periods of time (days to weeks) after dose reduction or even complete withdrawal of levodopa. The precise mechanism responsible for graftinduced dyskinesias is not known, but their presence suggests that transplantation of dopamine cells using current transplant protocols does not restore dopamine in a physiological manner. At present, we lack an understanding of how to prevent off-medication dyskinesia and this side effect remains an obstacle to further clinical testing of dopamine cell-based therapies in PD.

Fetal dopamine neurons transplanted 11 to 14 years earlier had decreased staining for the dopamine transporter (DAT) and contained intracellular inclusions identical to Lewy bodies, suggesting that they may have been affected by the PD pathologic process.

Summary 1-2 % of the general population over the age of 65 y Lewy bodies and Lewy neurites particularly in the substantia nigra pars compacta dopaminergic neurons projecting to striatum DA levels severely reduced in striatum. Resting tremor, bradykinesia, muscle rigidity Levodopa and other dopaminergic drugs No treatment which would prevent the continuous degeneration of nerve cells in the substantia nigra and resulting striatal DA loss